for kim woods only

Student Appeals Center – General Request Form

(This document will be used as the coversheet and SAC form)

This form should be used by all students requesting an academic policy exception.

Example: general admissions, application of credits, concurrent course enrollment, waiving a prerequisite, directed study courses, etc.

NOTE: This form is not to be used by students who were either: (1) Academically Disqualified, (2) Denied Admission after failing to meet the terms of their Provisional Admission, (3) General re-entry request, or (4) Course waiver requests.

Date:	IRN:
Last Name:		First Name:		PG	1
This section must be completed by Student Services.
Campus:
Campus Contact:
Campus Approver:		Title:
Original Program:		Version:
Original Start Date:		OLDA:
Enrollment Agreement sign date:
Specify policy(s) being appealed: (please be specific, including university or program policy #)
Optional Advisor Comments:

Assemble the SAC package in the following order:

1. Completed SAC form/coversheet

2. Student letter

3. Supporting documentation if applicable

4. Additional letter from advisor if applicable

5. Corporate Student Program Summary Report (Osiris Student Demographic Report)

Please submit the SAC package and electronic General web form for this appeal.

Please ensure all information is consistent between SAC package and web form, all personal/sensitive information has been redacted and sent to the Student Appeals Center shared inbox, and the advisor has fully reviewed appeal and options with student before submitting appeal.

General Request Form Continued	IRN:
Last Name:		First Name:		PG	2

This section must be completed by the student.

Please explain in your own words what you are requesting and the reason(s) for making such request.

(Please include any supporting documentation which you deem relevant as part of the appeal)

By signing this form, I understand I am providing Student Services permission to submit the appeal on my behalf:

Student Signature: Date: